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A nurse is caring for a client who has ITP. The nurse should notify the provider and report possible small-vessel clotting when which of the following is assessed?

A. Petechiae on the upper chest.
B. Hypotension
C. Cyanotic nail beds
D. Severe headache

1 Answer

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Final answer:

In an ITP patient, a nurse should report the finding of a severe headache to the provider as it might indicate small-vessel clotting and a potential brain hemorrhage. Other symptoms like petechiae, hypotension, and cyanotic nail beds, while also concerning, do not directly suggest small-vessel clotting in the brain.

Step-by-step explanation:

The student's question relates to the scenario of a nurse caring for a client with Immune Thrombocytopenic Purpura (ITP), which is a bleeding disorder characterized by an abnormally low number of platelets. Among the given options, the nurse should notify the provider and report possible small-vessel clotting if they assess severe headache. This symptom could indicate a more severe condition or complication such as a hemorrhage in the brain, particularly in the context of ITP where clotting and bleeding irregularities can have serious consequences.

Options such as petechiae on the upper chest are a common sign of ITP due to minor hemorrhages resulting from the low platelet count and do not directly indicate small-vessel clotting. Hypotension and cyanotic nail beds could be signs of other complications but are not as specific to the context of brain events as severe headache might be.

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